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2-50: Aetna's HCR Implementation Update

Oct 05, 2010

Health Care Reform: Implementation Update

Here’s a quick review of the changes and what Aetna is doing to make sure your customers’ plans are ready when they renew. You can also find more detail on these topics under Timeline and Q&As on the Health Care Reform page on


Covering dependent children to age 26
All plans must cover dependent children up to the age of 26. This is regardless of the dependent’s marital status, financial dependence, student status, or employment status. 
Grandfathered plans do not have to cover dependents who are eligible for employer coverage other than through their parents. Aetna's insured plans also will comply with any state laws that already require coverage beyond age 26.

(Aetna’s Individual and Small Group plans added this coverage earlier this year. Larger groups had the option of adding it at that time.)

Aetna is adding notices to all of their enrollment kits, so your customers’ employees know they can add these dependents to their plan.

100 percent coverage of preventive care services
All plans (except grandfathered plans) will provide coverage with no member cost sharing for recommended preventive care services, when provided in network.

Aetna has developed a list of covered preventive services. The list is based on their interpretation of the preliminary final guidance released by the Department of Health and Human Services (HHS) in July 2010. Aetna will cover services on this list without cost sharing in their insured plans. They’re also sharing the list with their self-funded plan sponsors.

You can see the list in this communication that your customers can share with their plan members. It explains the preventive services covered without cost share. (Please see this version for members of Traditional Choice plans only.)

Finally, Aetna is providing doctors their network with information. This will help make sure they know about Aetna's preventive health coverage.

Annual and lifetime limits
Aetna has removed lifetime and annual dollar limits for essential benefits, both in and out of network, from all of their plans. (See the exception below for limited benefit plans). Annual frequency limits can still apply.

Anthem has based these changes on their assessment of which benefits are essential.  They will update this assessment as needed once HHS provides additional information.

Limited Benefit Plans: There is an exception for limited benefit plans (such as Aetna’s Affordable Health Choices plans). HHS has agreed to waive the restricted annual benefit limits for qualified limited benefit plans until other affordable options become available in 2014. Aetna is applying for an annual waiver for their Affordable Health Choices plans. They expect to get word soon.

Emergency services out of network
Aetna foresees little change in the way they cover emergency services in most of their plans. Aetna already applies an in-network cost-share to out-of-network emergency services. They also don’t require preauthorization for these services.

HHS had originally defined a payment formula for out-of-network emergency claims. However, in guidance issued September 20, 2010, HHS accepted Aetna's proposal that the formula not apply if the member is held harmless for any balance billing. This will enable Aetna to continue their current payment practices. Today, they pay the out-of-network provider based on the plan’s out-of-network allowance. This allowance varies by plan. They hold the member responsible only for the in-network cost share. Aetna will tell members to contact them if an out-of-network provider balance bills them for an emergency service. If this happens, Aetna will reimburse the member for the balance billed amount.

Aetna is expanding this hold harmless approach to their Traditional Choice and Open Choice plans. These are the only plans where it was not previously in effect. They are making their EOB messaging clearer regarding the fact they will hold the member harmless. They also are developing appropriate language for their plan documents.

Grievance and appeals
The law has a number of requirements around grievances and appeals. These include turnaround times for urgent care claims, expanded availability of external review, providing notices in a culturally/linguistically appropriate manner, and other provisions. Grandfathered plans are not required to meet these requirements.

Aetna is working on updates to their systems and processes to bring their plans into compliance.  They are working with their language vendor to identify language needs and provide information in a culturally/linguistically appropriate manner. They are also expanding the availability of external reviews as required.

In guidance issued September 20, 2010, HHS granted a good faith grace period until July 1, 2011 for the implementation of changes to urgent care claim turnaround times, EOBs and language requirements for notices. Those changes require system and process modifications which were not possible by the September 23, 2010 effective date. While enforcement action will not occur prior to July of 2011, Aetna will become compliant as soon as possible.

Pre-existing conditions
Aetna is removing the ability for plans (except grandfathered plans) to limit or exclude benefits or coverage based on pre-existing conditions for enrollees under the age of 19.

Choice of health care professionals
The law says health plans must allow members to choose any participating primary care provider. Plans must allow women to access ob/gyns without a referral or preauthorization, and allow pediatricians to be named as a child’s primary care provider. Aetna plans already include all of these provisions, and no changes are needed.

Please contact your b&p Group Sales Representative if you have any questions - 888.722.3373.

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